Allergy and Airway |

Diagnosis of Posttransplant Lymphoproliferative Disorder (PTLD) in a Lung Transplant Recipient Using Electromagnetic Navigational Bronchoscopy FREE TO VIEW

Dhruv Joshi, MBBS; Thomas Gildea, MD; Marie Budev, DO
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Cleveland Clinic, Cleveland, OH

Chest. 2013;144(4_MeetingAbstracts):18A. doi:10.1378/chest.1703322
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SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: PTLD in lung transplantation has a higher incidence than all other solid organs, with earlier presentation within the thorax. PTLD requires histological morphology, immunophenotype, clonality and in situ testing for Epstein Barr Virus-encoded RNA (EBER) for complete diagnosis since this will greatly impact therapy. We present a unique case of early PTLD using navigational bronchoscopy.

CASE PRESENTATION: 52 yo s/p heart redo-lung transplant for cardiomyopathy and Stage 3 bronchiolitis obliterans (EBV donor positive, recipient positive). He received rabbit thymoglobulin for renal protection as induction therapy and was maintained on a standard regimen of tacrolimus, mycophenolate and prednisone for immunosuppression and valgancyclovir for antiviral prophylaxis. Ten weeks post transplant he presented with fevers and generalized fatigue and underwent CT chest which revealed a right lower lobe nodule(1.5 cm) and left lower lobe nodule(1 cm). Fluro-2-deoxy-D-glucose (FDG-PET) scan demonstrated bilateral avid nodules(SUV max 7.4 and 7 respectively). He subsequently underwent an electromagnetic navigation bronchoscopy(ENB) with peripheral EBUS(superDimenson, iLogic system Plymouth MN, USA) where RLL nodule transbronchial needle aspiration was performed using supertrax needle and fluoroscopically guided transbronchial biopsies were sent for pathology. Histopathological examination of the transbronchial biopsy revealed Epstein-Barr Virus(EBV) associated B-cell lymphoproliferative disorder. Immunohistochemical stains and chromogenic in situ hybridization for EBER were positive. In addition, flow cytometry of the transbronchial fine needle aspirate had monotypic kappa B-cell population consistent with post-transplant lymphoproliferative disorder(PTLD).

DISCUSSION: To the best of our knowledge ENB guided transbronchial biopsies have not been used previously to successfully diagnose PTLD. Above we present an unusual case of pure lung involvement of PTLD where navigational bronchoscopy and transbronchial biopsies led to a prompt positive diagnosis, obviating the need for more invasive procedures such as a surgical lung biopsy for more tissues. Adequate tissue samples are needed for diagnosis and ancillary testing to provide insight into additional features of PTLD that might be necessary to guide appropriate therapy.

CONCLUSIONS: ENB with EBUS and transbronchial biopsies may be a useful means of diagnosing pulmonary PTLD and avoiding more invasive techniques to obtain adequate tissues sample for histopathology and ancillary testing.

Reference #1: Post transplant Lymphoproliferative Disease after Lung Transplantation. Neuringer, IP

Reference #2: Pulmonary nodules in lung transplant recipients: etiology and outcome. Lee P, Minai OA, et al

Reference #3: Lung retransplantation after posttransplantation lymphoproliferative disorder (PTLD): a single-center experience and review of literature of PTLD in lung transplant recipients. Raj R, Frost AE

DISCLOSURE: The following authors have nothing to disclose: Dhruv Joshi, Thomas Gildea, Marie Budev

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